Endocrinology/Primary Care Pharmacy Collaboration vs Endocrinology Care Alone in Patients With Type 2 Diabetes and A1c >9.

Background: Type 2 diabetes (T2D) requires close collaboration between patients and their care management team, often including endocrinology. Primary care pharmacist impact on diabetes management in collaboration with endocrinology is not well established. Objective: To assess if pharmacy and endocrinology collaboration results in a greater A1c reduction in patients with T2D vs endocrinology alone. Methods: This retrospective, observational cohort study was conducted in adult outpatients with T2D and baseline A1c >9% who saw endocrinology within 1 year preceding the study period (January 1, 2021 to January 1, 2022). Patients were included if they had a follow-up A1c 6 months (±90 days) from index date and completed at least 1 endocrinology visit during the study period. Patients managed by endocrinology/primary care pharmacist collaboration (Endo/PharmD) were compared with those who received endocrinology care alone (Endo). Primary outcome was change in A1c from baseline to 6 months. Secondary outcomes included total number of completed visits and percentage of patients achieving A1c <6.5%, <7%, <8%, and <9% between groups at 6 months. Results: A total of 418 patients were included (22 Endo/PharmD, 396 Endo). The change in follow-up A1c was not significantly different between groups, -0.481% (standard error [SE] = 0.396); P = 0.6179. Endo/PharmD patients had significantly more provider visits during the study period (5.3 ± 2.3 vs 2.3 ± 1.2; P < 0.001). No significant difference was observed in odds of A1c goal attainment between groups at 6 months. Conclusion and Relevance: Endocrinology/primary care pharmacist collaboration occurred infrequently but was associated with a trend toward greater A1c reduction in patients with T2D and A1c >9%.

Pharmacist involvement in a comprehensive remote monitoring and telemanagement program.

PURPOSE: To describe the role of the pharmacist in and initial outcomes of a remote monitoring and telemanagement program implemented to proactively provide outreach to high-risk patients during the coronavirus disease 2019 (COVID-19) pandemic. SUMMARY: A remote monitoring and telemanagement program was developed at a large, nonprofit, multicenter, academic health system as an innovative way to manage patients at risk for decompensation of their chronic diseases in the midst of the COVID-19 pandemic. The program mobilized an interprofessional workforce including nurses, medical assistants, social workers, virtualists, patient schedulers, and ambulatory care pharmacists. Patient outreach included a combination of telephone calls and digital outreach. The goal was to monitor patients' health status remotely and assess for early signs of decompensation. Pharmacists conducted telephone outreach to answer patients' medication questions and address signs and symptoms of worsening chronic conditions. Pharmacists were able to utilize an existing collaborative practice agreement (CPA) to adjust medication therapy and order laboratory tests as needed for safety and efficacy monitoring. Since the program's inception in April 2020 through January 2021, pharmacists have addressed over 1,600 medication questions or instances of worsening clinical signs and symptoms. CONCLUSION: A comprehensive remote monitoring and telemanagement program utilized a multidisciplinary team to monitor high-risk patients during the COVID-19 pandemic. Pharmacists contributed to chronic disease management via the use of a comprehensive CPA, allowing medications to be started, stopped, or adjusted on the basis of patients' needs, to improve population health management and reduce workload for primary care providers who were addressing new and emerging issues during the pandemic.

Antiobesity drug therapy: An individualized and comprehensive approach.

Obesity affects 42% of US adults and has a devastating impact on health. Although many patients initially lose weight with diet and exercise, long-term weight loss is difficult to achieve. Pharmacotherapy, as part of a comprehensive plan, can help patients lose weight and avoid regaining it. Choosing an antiobesity drug regimen should be an individualized, shared decision-making process that accounts for patient preferences, comorbidities, and out-of-pocket costs. We review antiobesity drugs and propose an individualized and comprehensive approach to obesity management.

Evaluation of multidisciplinary weight loss shared medical appointments.

OBJECTIVES: A multidisciplinary weight loss shared medical appointment (SMA) was created to help patients with weight management. The study objective was to evaluate the change in weight in patients participating in weight loss SMAs. The secondary objective was to evaluate the change in patients' cardiometabolic risk factors. SETTING: The study took place in Beachwood, OH, at a family medicine clinic associated with an academic medical center. PRACTICE DESCRIPTION AND INNOVATION: Groups of 10 to 15 overweight and obese patients participated in weight loss SMAs in a family medicine clinic. The provider team included a family practice physician, a pharmacist, and a registered dietician. The pharmacist assisted with medication optimization to assist with weight management. EVALUATION: This retrospective observational study evaluated weight loss in patients who attended at least 1 weight loss SMA over a 9-month period. Weight loss and other cardiometabolic risk factors were compared from the time of the first SMA, 3 months after the first SMA, and at the end of the study period. RESULTS: A total of 222 patients attended at least 1 weight loss SMA. The mean weight loss was 4.0 ± 5.1 kg (3.8%) at 3 months and 4.4 ± 5.9 kg (4.1%) at the end of the study period. At 3 months, 38.7% of patients achieved 5% weight loss, and 41% of patients achieved 5% weight loss at the end of the study period. Patients also had a significant reduction in body mass index, blood pressure, and glycated hemoglobin. There was a significant correlation between the number of SMA visits attended and the amount of weight lost. CONCLUSION: Patients who attended a weight loss SMA lost weight and had modest improvements in cardiometabolic risk factors. Weight loss SMAs are a promising weight loss option to assist patients seen in the primary care setting.

Adjunct Antihyperglycemic Agents in Overweight and Obese Adults With Type 1 Diabetes.

OBJECTIVE: People with type 1 diabetes often have suboptimal glycemic control. The gold standard of treatment is basal-bolus insulin or subcutaneous insulin infusion via insulin pump. Although insulin therapy improves glycemic control, weight gain and hypoglycemia often limit achievement of hemoglobin A1C (A1C) goals. The number of people with type 1 diabetes who are overweight or obese is increasing, and there are many similarities between what was historically called type 1 and type 2 diabetes. Therefore, there is rationale for using antihyperglycemic agents that target other pathophysiological abnormalities to facilitate weight loss and improve glycemic control. DATA SOURCES: We performed a MEDLINE search from 1975 through October 2018 to identify articles that studied noninsulin agents in adults with type 1 diabetes and body mass index (BMI) ≥25 kg/m2. STUDY SELECTION AND DATA EXTRACTION: Identified articles were included if the study duration was ≥4 weeks, included ≥20 patients, and set mean baseline BMI ⩾25kg/m2. DATA SYNTHESIS: This review summarizes 32 clinical trials. Amylin mimetics, sodium-glucose-like transporter-2 inhibitors, and glucagon-like-peptide-1 receptor agonists demonstrate the greatest improvements in body weight and A1C. The most common adverse effects are hypoglycemia and ketosis. Relevance to Patient Care and Clinical Practice: Patients with type 1 diabetes may have interest in starting noninsulin agents. Clinicians need to be knowledgeable in the efficacy and adverse effect profile of these agents, specifically in people with type 1 diabetes. CONCLUSIONS: Adding noninsulin antihyperglycemic agents may benefit select overweight or obese adults with type 1 diabetes. These agents are off-label, and if used, close monitoring is essential.

Detection of DNA mismatch repair proteins in fresh human blood lymphocytes--towards a novel method for hereditary non-polyposis colorectal cancer (Lynch syndrome) screening.

BACKGROUND: A broad population-based assay to detect individuals with Lynch Syndrome (LS) before they develop cancer would save lives and healthcare dollars via cancer prevention. LS is caused by a germline mutation in a DNA mismatch repair (MMR) gene, especially protein truncation-causing mutations involving MSH2 or MLH1. We showed that immortalized lymphocytes from LS patients have reduced levels of full-length MLH1 or MSH2 proteins. Thus, it may be feasible to identify LS patients in a broad population-based assay by detecting reduced levels of MMR proteins in lymphocytes. METHODS: Accordingly, we determined whether MSH2 and MLH1 proteins can also be detected in fresh lymphocytes. A quantitative western blot assay was developed using two commercially available monoclonal antibodies that we showed are specific for detecting full-length MLH1 or MSH2. To directly determine the ratio of the levels of these MMR proteins, we used both antibodies in a multiplex-type western blot. RESULTS: MLH1 and MSH2 levels were often not detectable in fresh lymphocytes, but were readily detectable if fresh lymphocytes were first stimulated with PHA. In fresh lymphocytes from normal controls, the MMR ratio was ~1.0. In fresh lymphocytes from patients (N > 50) at elevated risk for LS, there was a bimodal distribution of MMR ratios (range: 0.3-1.0). CONCLUSIONS: Finding that MMR protein levels can be measured in fresh lymphocytes, and given that cells with heterozygote MMR mutations have reduced levels of full-length MMR proteins, suggests that our immunoassay could be advanced to a quantitative test for screening populations at high risk for LS.